Elbow Surgery (Tommy John) – Ulnar Collateral Ligament
Contributed by Stephanie Thomas, COF
To coincide with 2017 Opening Day, we decided to shed some light on a procedure we see quite often that is related to baseball and more specifically pitchers. In fact, a professional pitcher was the first person to have this elbow surgery about 40 years ago.
Who is Tommy John?
In 1974 Los Angeles Dodgers’ pitcher Tommy John was having a great 11th season in the Majors, starting 13-3. Many believed he would eventually be a Cy Young Award winner, but he damaged his ulnar collateral ligament (UCL), which is a ligament of the elbow. He was adamant about returning to baseball. John went to the team physician, Dr. Frank Jobe and asked him to develop an elbow surgery that would fix his UCL and allow him to pitch again. Dr. Jobe developed a technique that allowed John to return to pitching in 1976. Since then there have been different techniques developed to help repair the UCL.
Original Procedure – During Dr. Jobe’s procedure, he would harvest the patient’s palmaris longus in the wrist. It is important to note that not everyone has a palmaris longus; if the patient doesn’t have this ligament the surgeon may opt to harvest a different autograft (from patient’s body) such as the gracilis, plantaris, or a strip of the Achilles to complete the elbow surgery. You can test yourself by touching your thumb to your ring finger and twisting your wrist. The ligament will pop out (like the photo) if you have it.
Dr. Jobe utilizes the Figure 8 technique where he would drill two holes in the medial epicondyle and two holes into the ulna and feed the palmaris longus through. Then he would suture the tendon to itself. He also had to detach the flexor-pronator musculature at its origin which would cause the ulnar nerve to transpose.
Docking Technique – This technique, developed by Dr. David Altchek, it is different from the original technique in many ways. First it does not detach the muscle group, instead, it uses a muscle splitting technique. This procedure also does not drill as many holes, and the tendon is shaped into an “elongated D” instead of a figure-8. The tendon graft enters the humerus but never exits and is sutured to the bone.
What are the Signs and Symptoms of Ulnar Collateral Ligament Injury?
You may feel a “pop” on the inside of the elbow that is accompanied with pain and possible swelling. You could also notice that you are weaker when throwing. Always make sure you have your injury evaluated by a healthcare professional; an MRI may be ordered to determine if there is a tear in the ligament that requires elbow surgery.
Who should have “Tommy John” elbow surgery?
Surgical intervention should be discussed with your physician. There are conflicting ideas on how early is too early to for an athlete to have this procedure. Many believe that high school athletes should not have the surgery due to some athletes still growing, where others believe it is ok. You should also ask the doctor what type of technique he/she will be performing.
Treatment and Rehabilitation
If you decide to have “Tommy John’s” elbow surgery, you will be placed in an elbow range of motion orthosis, after the procedure, (we use the Breg T-chek, seen below) to help protect the elbow and to eliminate movement. The orthosis is also adjustable to allow for a controlled range of motion. When the time comes, you will begin physical therapy and rehabilitation to get back to throwing again. This whole process can take over a year. Discuss the timeline with your doctor.
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References Ellattrache N; Harne C; Mirzayan R; Sekiya J. Surgical Techniques in Sports Medicine. Lippincott Williams and Wilkins. 2007.  Vitale M. Ahmad C. The Outcome of Elbow Ulnar Collateral Ligament Reconstruction in Overhead Athletes: A Systematic Review. Am J Sports Med. 2008;36:1193-1205.  Borak T. Ulnar Collateral Ligament Reconstruction: A Look Inside Tommy John Surgery. The Surgical Technologist.2009;41:163-172.